International Journal of Cardiology 177 (2014) e113–e114
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Aortic coral reef as an unusual possible cause of heart failure Ludovic Berger a,⁎, Olivier Coffin a, Vladimir Saplacan b, Arnaud Pellissier c, Annette Belin b a b c
CHU de Caen, Department of Vascular Surgery, Université de Caen Basse-Normandie, Medical School, Caen, France CHU de Caen, Department of Cardiac Surgery, Caen, France CHU de Caen, Department of Cardiology, Caen, France
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 20 September 2014 Available online 28 September 2014 Keywords: Heart failure Abdominal aorta Atherosclerosis Endarterectomy
A 66-year-old man was admitted to the hospital for severe heart failure with dyspnea at rest, edema lasting for 3 months, and resistant hypertension. His medical history included bilateral ilio-femoral bypasses, tobacco abuse, and hypertension. Physical examination showed clinical signs of bilateral pleural effusion and pulmonary edema with the need for oxygen therapy. He presented poorly controlled hypertension requiring four antihypertensive medications. He did not complain of any sign of visceral ischemia such as diarrhea, weight loss, or abdominal pain. Biological tests revealed an elevated brain natriuretic peptide value of 1500 pg/mL (normal b 100 pg/mL). Liver tests revealed moderate cholestasis. Complete blood count, hemostasis, and renal function were normal. Transthoracic echocardiography demonstrated preserved left ventricular function, no valvular disease, and pulmonary hypertension (pulmonary artery pressure = 55 mm Hg). Cardiac output was 5 L/min, based on Doppler measurements. Coronarography showed insignificant coronary artery disease. Right catheterization confirmed the high cardiac output (CO) at 8 L/min with a cardiac index of 5 L/min/m2; pulmonary capillary wedge pressure was 16 mm Hg, and pulmonary artery pressure (PAP) was elevated at 60/21–35; and pulmonary vascular resistance was normal at 2.3 Wood (184 dyn · s/cm5). Systemic vascular resistance was normal (1570 dyn · s/cm5). The patient had no anemia, hyperthyroidism, or hypovitaminosis. Contrast-enhanced arterial phase computed tomography of the entire aorta showed an extensive exophytic plaque localized to the ⁎ Corresponding author at: Department of Vascular Surgery, CHU de Caen, Avenue de la Côte de Nacre, F-14000 Caen, France. Tel.: +33 2 31 06 44 45; fax: +33 2 31 06 51 65. E-mail address: [email protected] (L. Berger).
http://dx.doi.org/10.1016/j.ijcard.2014.09.083 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
paravisceral aorta, resulting in high-grade stenosis of the proximal aorta as well as the celiac, superior mesenteric, and both renal arteries (Fig. 1). The patient underwent surgical revascularization through a retroperitoneal aortic exposure and trapdoor aortic endarterectomy. Postoperative recovery was uneventful, without the need for antihypertensive medication, and the dyspnea was resolved. Immediately after surgery, the plasmatic brain natriuretic peptide value decreased to 140 pg/mL. He was discharged home 7 days later, and at 2 years later, remained asymptomatic. A control right catheterization confirmed the clinical result, with CO at 6 L/min and PAP improvement (42/18–26). A control computed tomography showed no recurrence of plaque in the paravisceral aorta (Fig. 2). Discussion. Coral reef aorta, first identified by Qvarfordt et al. [1], is a rare entity of calcifying aortic disease localized to the suprarenal aorta. The estimated frequency of this disease ranges between 0.6% and 1.8% [2]. Severe heart failure, prolonged pleural effusion, and post-capillary pulmonary hypertension comprise a rare symptomatology revealing coral reef aorta. Classical symptoms are intermittent claudication due to peripheral arterial occlusive disease; renovascular hypertension causing headache, vertigo, and visual symptoms; and chronic visceral ischemia causing diarrhea, weight loss, and abdominal pain. No data are available in the literature on heart failure and coral reef aorta. Satsu et al. [3] described the case of a patient presenting an acute heart failure due to coral reef thoracoabdominal aorta. They reported an after-load mismatch but not the hemodynamic status. Left ventricular function was low. Our patient had uncontrolled hypertension and pulmonary hypertension with increased capillary wedge pressure whereas systemic vascular resistance was normal and left ventricular function was preserved. The presentation of heart failure was not in favor of acquired coarctation, and the classical symptoms of coral reef aorta were not recognizable. A definitive diagnosis was difficult without the completion of computed tomographic imaging of the entire aorta. In our case, heart failure may have resulted from an increased after load and also from the activation of the renin–angiotensin system because of an obstacle in the aorta and renal arteries. The immediate and long-term outcomes after aortic endarterectomy were promising for the patient. The recovery of his heart failure was immediately impressive, and the surgical procedure did not cause any complication. Coral reef aorta is essentially treated by conventional surgery comprising thromboendarterectomy, resection of the calcified thrombus,
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L. Berger et al. / International Journal of Cardiology 177 (2014) e113–e114
Fig. 1. Preoperative three-dimensional (A) and two-dimensional (B) computed tomographic angiographic reconstructions of the aortic coral reef.
13.9–15.9% rate of postoperative complications requiring corrective surgery [2,4]. Conclusion. The case reported here is of particular relevance because it documents that visceral aortic tight stenosis might be responsible for heart failure with post-capillary pulmonary hypertension. Surgical treatment, such as aortic endarterectomy, can be performed for these patients with excellent recovery. Conflict of interest We have no conflict of interest to declare. References
Fig. 2. Postoperative two-dimensional computed tomographic angiographic reconstructions.
and graft replacement of the aorta, or placement of a thoracoabdominal bypass graft [2,4]. Direct aortic surgeries are more invasive, and some authors have described an operative mortality rate of 8.7–11.6% and a
[1] Qvarfordt PG, Reilly LM, Sedwiz NM, Ehrenfeld WK, Stoney RJ. ‘Coral reef’ atherosclerosis of the suprarenal aorta: a unique clinical entity. J Vasc Surg 1984;1:903–9. [2] Grotemeyer D, Pourhassan S, Rehbein H, Voiculescu A, Reinecke P, Sandmann W. The coral reef aorta—a single center experience in 70 patients. Int J Angiol 2007;16: 98–105. [3] Satsu T, Saga T, Kaneda T, Imura M. Congestive heart failure due to coral reef thoracoabdominal aorta. Interact Cardiovasc Thorac Surg 2011;13:684–5. [4] Sagban AT, Grotemeyer D, Rehbein H, Sandmann W, Duran M, Baizer KM, et al. Occlusive aortic disease as coral reef aorta—experience in 80 cases. Zentralb Chir 2010;135:438–44.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Aortic coral reef as an unusual possible cause of heart failure Ludovic Berger a,⁎, Olivier Coffin a, Vladimir Saplacan b, Arnaud Pellissier c, Annette Belin b a b c
CHU de Caen, Department of Vascular Surgery, Université de Caen Basse-Normandie, Medical School, Caen, France CHU de Caen, Department of Cardiac Surgery, Caen, France CHU de Caen, Department of Cardiology, Caen, France
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 20 September 2014 Available online 28 September 2014 Keywords: Heart failure Abdominal aorta Atherosclerosis Endarterectomy
A 66-year-old man was admitted to the hospital for severe heart failure with dyspnea at rest, edema lasting for 3 months, and resistant hypertension. His medical history included bilateral ilio-femoral bypasses, tobacco abuse, and hypertension. Physical examination showed clinical signs of bilateral pleural effusion and pulmonary edema with the need for oxygen therapy. He presented poorly controlled hypertension requiring four antihypertensive medications. He did not complain of any sign of visceral ischemia such as diarrhea, weight loss, or abdominal pain. Biological tests revealed an elevated brain natriuretic peptide value of 1500 pg/mL (normal b 100 pg/mL). Liver tests revealed moderate cholestasis. Complete blood count, hemostasis, and renal function were normal. Transthoracic echocardiography demonstrated preserved left ventricular function, no valvular disease, and pulmonary hypertension (pulmonary artery pressure = 55 mm Hg). Cardiac output was 5 L/min, based on Doppler measurements. Coronarography showed insignificant coronary artery disease. Right catheterization confirmed the high cardiac output (CO) at 8 L/min with a cardiac index of 5 L/min/m2; pulmonary capillary wedge pressure was 16 mm Hg, and pulmonary artery pressure (PAP) was elevated at 60/21–35; and pulmonary vascular resistance was normal at 2.3 Wood (184 dyn · s/cm5). Systemic vascular resistance was normal (1570 dyn · s/cm5). The patient had no anemia, hyperthyroidism, or hypovitaminosis. Contrast-enhanced arterial phase computed tomography of the entire aorta showed an extensive exophytic plaque localized to the ⁎ Corresponding author at: Department of Vascular Surgery, CHU de Caen, Avenue de la Côte de Nacre, F-14000 Caen, France. Tel.: +33 2 31 06 44 45; fax: +33 2 31 06 51 65. E-mail address: [email protected] (L. Berger).
http://dx.doi.org/10.1016/j.ijcard.2014.09.083 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
paravisceral aorta, resulting in high-grade stenosis of the proximal aorta as well as the celiac, superior mesenteric, and both renal arteries (Fig. 1). The patient underwent surgical revascularization through a retroperitoneal aortic exposure and trapdoor aortic endarterectomy. Postoperative recovery was uneventful, without the need for antihypertensive medication, and the dyspnea was resolved. Immediately after surgery, the plasmatic brain natriuretic peptide value decreased to 140 pg/mL. He was discharged home 7 days later, and at 2 years later, remained asymptomatic. A control right catheterization confirmed the clinical result, with CO at 6 L/min and PAP improvement (42/18–26). A control computed tomography showed no recurrence of plaque in the paravisceral aorta (Fig. 2). Discussion. Coral reef aorta, first identified by Qvarfordt et al. [1], is a rare entity of calcifying aortic disease localized to the suprarenal aorta. The estimated frequency of this disease ranges between 0.6% and 1.8% [2]. Severe heart failure, prolonged pleural effusion, and post-capillary pulmonary hypertension comprise a rare symptomatology revealing coral reef aorta. Classical symptoms are intermittent claudication due to peripheral arterial occlusive disease; renovascular hypertension causing headache, vertigo, and visual symptoms; and chronic visceral ischemia causing diarrhea, weight loss, and abdominal pain. No data are available in the literature on heart failure and coral reef aorta. Satsu et al. [3] described the case of a patient presenting an acute heart failure due to coral reef thoracoabdominal aorta. They reported an after-load mismatch but not the hemodynamic status. Left ventricular function was low. Our patient had uncontrolled hypertension and pulmonary hypertension with increased capillary wedge pressure whereas systemic vascular resistance was normal and left ventricular function was preserved. The presentation of heart failure was not in favor of acquired coarctation, and the classical symptoms of coral reef aorta were not recognizable. A definitive diagnosis was difficult without the completion of computed tomographic imaging of the entire aorta. In our case, heart failure may have resulted from an increased after load and also from the activation of the renin–angiotensin system because of an obstacle in the aorta and renal arteries. The immediate and long-term outcomes after aortic endarterectomy were promising for the patient. The recovery of his heart failure was immediately impressive, and the surgical procedure did not cause any complication. Coral reef aorta is essentially treated by conventional surgery comprising thromboendarterectomy, resection of the calcified thrombus,
e114
L. Berger et al. / International Journal of Cardiology 177 (2014) e113–e114
Fig. 1. Preoperative three-dimensional (A) and two-dimensional (B) computed tomographic angiographic reconstructions of the aortic coral reef.
13.9–15.9% rate of postoperative complications requiring corrective surgery [2,4]. Conclusion. The case reported here is of particular relevance because it documents that visceral aortic tight stenosis might be responsible for heart failure with post-capillary pulmonary hypertension. Surgical treatment, such as aortic endarterectomy, can be performed for these patients with excellent recovery. Conflict of interest We have no conflict of interest to declare. References
Fig. 2. Postoperative two-dimensional computed tomographic angiographic reconstructions.
and graft replacement of the aorta, or placement of a thoracoabdominal bypass graft [2,4]. Direct aortic surgeries are more invasive, and some authors have described an operative mortality rate of 8.7–11.6% and a
[1] Qvarfordt PG, Reilly LM, Sedwiz NM, Ehrenfeld WK, Stoney RJ. ‘Coral reef’ atherosclerosis of the suprarenal aorta: a unique clinical entity. J Vasc Surg 1984;1:903–9. [2] Grotemeyer D, Pourhassan S, Rehbein H, Voiculescu A, Reinecke P, Sandmann W. The coral reef aorta—a single center experience in 70 patients. Int J Angiol 2007;16: 98–105. [3] Satsu T, Saga T, Kaneda T, Imura M. Congestive heart failure due to coral reef thoracoabdominal aorta. Interact Cardiovasc Thorac Surg 2011;13:684–5. [4] Sagban AT, Grotemeyer D, Rehbein H, Sandmann W, Duran M, Baizer KM, et al. Occlusive aortic disease as coral reef aorta—experience in 80 cases. Zentralb Chir 2010;135:438–44.
